The Public Health Implications of the 2010 Dietary Guidelines

An Expert Interview With David L. Katz, MD, MPH

Janet Kim, MPH


February 15, 2011

In This Article

The Food and Physical Activity Environment

Medscape: An addition to the 2010 DGA is the chapter that focuses on a call to action to improve the current food and physical activity environment and to advocate for better health policies. This section outlines ways to enlist all segments of society to become involved and invested with increasing access, affordability, and attractiveness of healthier options to all Americans. These systemwide changes are intended to help individuals adopt the new recommendations with greater ease.

In your blog posting, you mentioned that this new section "provides the 'how to' partner for the 'what to' guidelines." As admirable as this mission is, however, it seems likely to be a significant challenge to execute.

As a public health professional, what supports and resources do you consider would need to be in place to improve existing strategies and policies and facilitate the development and implementation of new ones to meet these recommendations? In other words, what's essential to allow the seamless transition from the "what to" to the "how to"?

Lastly, what role could healthcare providers play in this process?

Dr. Katz: It is, in some ways, the $64,000, $1 million, or 1$ billion question: How do we get this job done? We've been wrestling with this question for a long time. It could easily be a question too big to answer, and I could put up my hands and say, "I don't know." However, I think we can answer this question: How do we go from the "what to," which, by the way, we've been doing every 5 years for a long time, to the "how to"? Albert Einstein defined insanity as "doing the same thing over and over again, and expecting different results." Every 5 years, new dietary guidelines are issued, and every 5 years, the public ignores them and keeps eating the typical American diet. Perhaps a bit crazy?

One of the things we might ask ourselves is: Is this a waste of resources? In other words, is this really the problem: that people don't know what a healthy diet is? Or is the problem that nobody is able to get there from here? Maybe we need to devote all of our effort and all of our resources for the foreseeable future into turning the road less traveled into the path of lesser resistance: to focus on the "how to." My answer to how do we transition from the "what to" to the "how to" involves just 2 key elements: vision and passion.

In terms of the vision -- and I don't profess to have the right vision, but just a vision that makes sense to me and can be operationalized -- I think of the factors that make it hard to eat well or, for that matter, hard to be physically active, as being akin to the waters of a flood. For example, all of the highly processed, extremely tasty, energy-dense, conveniently available, relatively inexpensive foods that we find everywhere we go -- part of the flood. Huge amounts of marketing dollars are being used to encourage us to eat those very foods -- part of the flood. A vast proliferation of labor-saving technology to do everything muscles used to do at both work and play -- part of the flood. My vision is: We are subject to this flood tide of obesogenic and morbidigenic factors in our daily lives. The question then becomes: In a vision like that, what must you do to contain the flood? The answer is readily apparent: Build a levee.

What guides my own work is the notion that no one thing that we do will fix all of this. Everything that makes modern living "modern" is part of the problem. We need to construct systematically solutions every place people and food come together. For example, we need better nutrition education of kids in schools. We need better nutrition education of adults, perhaps at work sites. We need better nutritional offerings. Ideally, we need financial incentives for both individuals to choose more nutritious food and for manufacturers to provide them. We need nutrition guidance systems in supermarkets and restaurants so that everybody can unfailingly tell at a glance what is the more nutritious choice. I'm involved in just such an effort, called NuVal, where we've scored over 90,000 foods on a 1-100 scale: the higher the number, the more nutritious the food. Experts should do the heavy lifting in this area so that the individual shopper -- the busy mom in the supermarket -- doesn't have to. Otherwise, she's left to try to navigate past marketing messages on the front of the pack and nutrition facts that are on the back: something she has never been trained to synthesize into a whole story about whether this is, or is not, the better choice. I think we, as clinicians, need to be better agents of change by providing high-quality lifestyle counseling. We have developed a freely available CME program to support that aim with an approach that is realistic for busy clinical practices through our nonprofit foundation, Turn the Tide.

We need to do a lot of things in a lot of places right before we have an antiobesity, antidiabetes levee that tops the floodwater, and turns the tide. With each little thing that we do, we can't ask the question: Is this enough? Each little thing that we do right in some setting is similar to a sandbag in a levee. No matter how good a sandbag is, it's never more than part of the solution. We have to start looking at systematically converting our society into one that eats well by making eating well the easy choice, the default choice, the normative choice. Ditto for physical activity. It will be a long, arduous job. Everybody is either part of the solution, ie, they get their hands on a sandbag and help stack it, or they're part of the problem because they're abdicating. We should not abdicate!

Then there's passion. I think that's the thing that sets people in motion on an arduous journey in the first place. They have to really care. Every mom and every dad and, for that matter, every clinician need to know that food is the construction material and the only construction material for the growing body of a child. Food is the construction material that replaces the hundreds of millions of cells that are being turned over by an adult body every day. The quality of food is a critical consideration in the quality of health, and we all have cause to be passionate about that. If all of us were -- if, for instance, all parents were passionate advocates for better nutrition -- it would be a powerful force for change. We become the largest special-interest group of all.

I think it is possible to make the conversion from "what to" to "how to" if we see the problem and the solution correctly. Chronic disease related to diet and lifestyle will be very, very hard to fix, but not because it's complicated. We need to eat closer to nature, consume less and better food, and be more physically active: It's really that simple. But to do it, we need to pave the way, not just rely on people's will. To pave the way, we need to be passionate about getting there from here.

Clinicians should be part of the solution, but we need to recognize that most of the action here is not clinical. Most of the practices that individuals engage in that influence health at its origins have nothing to do with the clinical setting. They're much more about feet and forks than stethoscopes and scalpels. We are good at treating disease, but less good at cultivating health at its origins.

We need support in schools, work sites, churches, shopping malls, cinemas, restaurants, and supermarkets. Then I think the ideal role for the clinician is to know about those supports in his or her community and be able to encourage the use of the ones that meet an acceptable standard. When we are good agents of change -- when we are good lifestyle counselors -- we should also be surrounded by an array of good programming that we can recommend.

By the way, we're testing this very model in and around Independence, Missouri, where we have been building health promotion programs, starting in the schools, then involving supermarkets and the area clinicians, and trying to make everybody part of a comprehensive solution. When you can connect the dots that way, you get the local levee built a whole lot faster and can really turn the tide.

I think that clinicians need to be somewhat humble about all of this. We do not interact with people long enough, often enough, or in the right settings to be the major basis for them changing the way they eat. We can facilitate such change, but we're going to need help. We can be part of the solution, or by failing to address this, we can be part of the problem. I would argue that we can and should be part of the solution; however, it's unreasonable, unrealistic, and a formula for frustration to think that if we recommend healthful eating and physical activity, no matter how hard the physical and social environments make it to follow our advice, that our patients will do so anyway. Again, we need to cultivate our patients' will, but the body politic needs to help pave much easier ways to get there from here.


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